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Surgeon slammed over woman's staple death

A coroner has recommended disciplinary action against a surgeon he said had provided grossly inadequate care to a mother who died six months after a botched stomach stapling procedure.

Julienne McKay-Hall, 46, underwent the elective surgery at St John of God Hospital in Murdoch, in Perth's south, in November 2007 after failing to lose weight despite various diets and stints at a health farm.

After the stapler being used in the operation misfired, subsequent complications meant Ms McKay-Hall was in and out of hospital for further procedures over the next few months.

On May 18, 2008 she was pronounced brain dead and died on May 19 - just over six months after her initial operation.

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Following an inquest late last year, WA coroner Alastair Hope has handed down a scathing assessment into the post-operative care received by Ms McKay-Hall, saving his harshest criticism for surgeon Hairul Ahmad.

Highlighting the surgeon's failure to diagnose a sepsis infection, despite the increased risk following the stapler failure, Mr Hope said there were "inexcusable failures" by Dr Ahmad that led to "catastrophic consequences".

"What is clear is that while the deceased became more and more seriously ill, no one was adequately monitoring her condition," Mr Hope said.

"The question is how it was the deceased was allowed to become so seriously ill without robust intervention at a much earlier stage."

Ruling Ms McKay-Hall's death as misadventure, Mr Hope said the poor quality of treatment and care by Dr Ahmad and nursing staff at the hospital "directly contributed to her death".

He said inactions by Dr Ahmad, including failing to read notes, declining to come back to the hospital despite Ms McKay-Hall's failing health, and failing to act quicker when he knew of the sepsis infection, warranted more action.

Counsel assisting the coroner, Anthony Willinge, had told the inquest Ms McKay-Hall was obese, weighing about 111kg before the initial operation.

Reading from a section of Dr Ahmad's notes, Mr Willinge said because one of the staples did not fire properly, the area was over-sewn and Tisseel glue was used on the staple line.

After complications caused by the sepsis infection, Ms McKay-Hall was readmitted to hospital on May 12, 2008 for another procedure, but died seven days later.

The cause of death was concluded as complications following cardio-respiratory arrest, in association with an air embolism during a gastroscopy and stenting procedure for a chronic abdominal fistula after a sleeve gastrectomy.

Mr Hope said he would be sending his findings to WA's Department of Health in a bid to mandate levels of communications between nurses in the state's hospitals, and promote consistency of actions in medical emergencies.

Tanya Watson, a lawyer for Ms McKay-Hall's family, said their suspicions that her treatment had been inadequate had been vindicated, and they were now considering whether to pursue a compensation claim against the hospital or Dr Ahmad.